Couples Relationship Roadtrip™ Questionnaire
Too many times in life you do not take advantage of all the learning that your relationships teach you. This can cause dissatisfaction in your current relationship, becoming the downfall of even the most promising love affair.

Relationship Roadtrip™ provides couples the opportunity to learn the tools needed to achieve long lasting satisfaction, better communication, improved intimacy and connection, as well as the success you have been longing for in your relationship!

Please take your time to complete the Relationship Roadtrip™ questionnaire below. It should take you no more than 15-20 minutes to complete, and must be done in one sitting so please plan accordingly. Your answers are COMPLETELY confidential and will not be shared by me with your partner.  Please answer each question honestly and to the best of your ability. The information you share with me will be used to create your Roadmap, so the more honest and complete your answers, the better your Roadmap will turn out.

You should know everything you need to answer all the questions below.  The only one you may need to look up is your time of birth (or time of day of your birth).  Please have that information available prior to beginning this questionnaire.

I invite you to close your eyes and take a few deep, cleansing breaths. When you are ready, open your eyes and have fun with this process!


Email *
Your Name *
Your date of birth
MM
/
DD
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YYYY
Your Partner's Name *
Couples Relationship Roadtrip™ Questionnaire
How long have you been in a partnership or committed relationship (include any time spent dating as well if you are married) *
What is your relationship status? *
Required
How many significant relationships (one year or longer) did you have prior to your current partner? *
What were you seeking when you committed to your partner? (this information is COMPLETELY confidential and will not be shared with your partner. Please answer honestly so I can support you in the best way possible) Please select all that apply. *
Required
What are the names of the top five people you spend your time with (not including your spouse or children)?
Please assign a short one word descriptor for each of the people you named in the last question (please list as "name - descriptor word")
What do you think are your biggest challenges in your marriage or partnership? *
Required
What have you tried or are willing to try to resolve your relationship woes? *
Required
Besides any children you may have, what do you see as your biggest accomplishments because of your marriage/partnership? *
What couples come to mind that you know who you would like to model your relationship after? *
If time and money were not an issue for you and your partner, would anything change about the couple you just selected? *
What do you see as your responsibilities in this relationship (includes handling finances, cooking, housework/yard work, responsibilities around children, etc.)? *
Where were you born? (city & state or city & country if outside the United States) *
Where did you grow up? (city & state or city & country if outside the United States) *
At the end of your life, what would you like to look back upon and celebrate from this relationship? *
For the next several questions, please read each word carefully. You will be asked to select the ONE word which describes you BEST and the ONE word which describes you LEAST.
MOST like me
LEAST like me
Cheerful
Cooperative
Obliging
Persuasive
Select the ONE word that BEST describes you and the ONE word which LEAST describes you.
MOST like me
LEAST like me
Happy
Moderate
Orderly
Original
Select the ONE word that BEST describes you and the ONE word which LEAST describes you.
MOST like me
LEAST like me
Animated
Forceful
Neighborly
Tolerant
Select the ONE word that BEST describes you and the ONE word which LEAST describes you.
MOST like me
LEAST like me
Correct
Extroverted
Loyal
Restless
Select the ONE word that BEST describes you and the ONE word which LEAST describes you.
MOST like me
LEAST like me
Aggressive
Fearful
Playful
Steady
Select the ONE word that BEST describes you and the ONE word which LEAST describes you.
MOST like me
LEAST like me
Appealing
Diplomatic
Gentle
Stubborn
Select the ONE word that BEST describes you and the ONE word which LEAST describes you.
MOST like me
LEAST like me
Bold
Even-Tempered
Outgoing
Receptive
Select the ONE word that BEST describes you and the ONE word which LEAST describes you.
MOST like me
LEAST like me
Controlled
Generous
Popular
Positive
Select the ONE word that BEST describes you and the ONE word which LEAST describes you.
MOST like me
LEAST like me
Good Listener
Persistent
Level-Headed
Soft-Spoken
Select the ONE word that BEST describes you and the ONE word which LEAST describes you.
MOST like me
LEAST like me
Determined
Good Mixer
Satisfied
Timid
Select the ONE word that BEST describes you and the ONE word which LEAST describes you.
MOST like me
LEAST like me
Brave
Convincing
Humble
Kind
Select the ONE word that BEST describes you and the ONE word which LEAST describes you.
MOST like me
LEAST like me
High-Spirited
Nervy
Obedient
Peaceful
Select the ONE word that BEST describes you and the ONE word which LEAST describes you.
MOST like me
LEAST like me
Enthusiastic
Harmonious
Nonchalant
Pioneering
Select the ONE word that BEST describes you and the ONE word which LEAST describes you.
MOST like me
LEAST like me
Adaptable
Welcoming
Daring
Lenient
Select the ONE word that BEST describes you and the ONE word which LEAST describes you.
MOST like me
LEAST like me
Resolute
Easily Led
Good-Natured
Inspiring
Select the ONE word that BEST describes you and the ONE word that LEAST describes you.
MOST like me
LEAST like me
Assertive
Light-Hearted
Respectful
Sincere
Select the ONE word that BEST describes you and the ONE word which LEAST describes you.
MOST like me
LEAST like me
Accommodating
Entertaining
Outspoken
Restrained
Select the ONE word that BEST describes you and the ONE word which LEAST describes you.
MOST like me
LEAST like me
Contented
Tenacious
Emotional
Introspective
Select the ONE word that BEST describes you and the ONE word which LEAST describes you.
MOST like me
LEAST like me
Accurate
Conventional
Lively
Vigorous
Select the ONE word that BEST describes you and the ONE word which LEAST describes you.
MOST like me
LEAST like me
Spunky
Charming
Disciplined
Sympathetic
Select the ONE word that BEST describes you and the ONE word which LEAST describes you.
MOST like me
LEAST like me
Careful
Considerate
Communicative
Efficient
Select the ONE word that BEST describes you and the ONE word which LEAST describes you.
MOST like me
LEAST like me
Cautious
Confident
Patient
Strong-Willed
Select the ONE word that BEST describes you and the ONE word which LEAST describes you.
MOST like me
LEAST like me
Agreeable
Self-Reliant
Sociable
Submissive
Select the ONE word that BEST describes you and the ONE word which LEAST describes you.
MOST like me
LEAST like me
Adventurous
Companionship
Resigned
Willing
Select the phrase that BEST describes you.
MOST like me
Directing/Controlling of Others
Interacting/Engaging of Others
Select the phrase that BEST describes you.
MOST like me
Accommodating/Accepting of Others
Observing/Assessing of Others
Select the phrase that BEST describes you.
MOST like me
Directing/Controlling of Others
Accommodating/Accepting of Others
Select the phrase that BEST describes you.
MOST like me
Directing/Controlling of Others
Observing/Assessing of Others
Select the phrase that BEST describes you.
MOST like me
Interacting/Engaging of Others
Accommodating/Accepting of Others
Select the phrase that BEST describes you.
MOST like me
Interacting/Engaging of Others
Observing/Assessing of Others
Tell me about your family dynamics.  Do you have any siblings? Please list their birth years in relation to YOU  (i.e. brother 2 years older and sister 6 years younger). Please include all siblings (alive and deceased. If the latter, please list YOUR age when it happened). *
Briefly tell me about any significant happenings that occurred which disrupted your family unit while you were growing up. *
Tell me about your family dynamics. At what time of day were you born (if you know the exact time of your birth, please provide in the "Other" space provided) *
Tell me about your family dynamics. What roles did your parents play in your upbringing? *
Who is the most significant person in your life right now and why? *
Who has had the most impact in your life and why? *
What are your strengths, gifts and talents? *
What are your most important values? *
At this point in time, how would you describe your general state of well being, energy levels and self care? *
What brings you joy and fulfillment? *
What are you passionate about? *
Are you and your partner well matched sexually? *
If you answered sometimes or no in the last question, please answer what you wish you could change (sexually) about your partner? *
Required
What would you most like to change about your relationship right now?   *
If I could wave a magic wand right now, how do you wish your relationship looked and felt?   *
Clear selection
What do you want to achieve from our coaching sessions? *
How can I best guide/support you on this Roadtrip? *
Consent and privacy policy:
Teresa Lodato, CPCC and Becoming Aware™ (“Company,” “we,” or “us”) respects your privacy and is committed to protecting it through this Privacy Policy.

This Privacy Policy governs your access to and use of Relationship Roadtrip™, including any content, functionality and services offered on or through Relationship Roadtrip™ (the "Program"), whether as a guest or a registered user.

When accessing the Relationship Roadtrip™ program, the Company will learn certain information about you, both automatically and through voluntary actions you may take, during your visit. This policy applies to information we collect on your application and in email, text, or other electronic messages between you and the Program.

Please read the Privacy Policy carefully before you start to use Relationship Roadtrip™. By using the Application or by clicking to accept or agree to the Terms of Use when this option is made available to you, you accept and agree to be bound and abide by the Privacy Policy. If you do not want to agree to the Privacy Policy, you must not access or use the Website.

Children Under The Age Of 13

Our Program is not intended for children under 13 years of age. No one under age 13 may provide any information to or on the Website. We do not knowingly collect personal information from children under 13. If you are under 13, do not use or provide any information on this page or on or through any of its features/register on the program page, make any purchases through the Website, use any of the interactive or public comment features of this program or provide any information about yourself to us, including your name, address, telephone number, email address, or any screen name or user name you may use.

If we learn we have collected or received personal information from a child under 13 without verification of parental consent, we will delete that information. If you believe we might have any information from or about a child under 13, please contact us at csteam@teresalodato.com.

Information We Collect About You

When you access the Program, the Company will learn certain information about you during your visit.

Information You Provide To Us. The Program provides various places for users to provide information. We collect information that users provide by filling out forms on the Website, communicating with us via contact forms, responding to surveys, search queries on our search feature, providing comments or other feedback, and providing information when ordering a product or service via the Website.

We use information you provide to us to deliver the requested product and/or service, to improve our overall performance, and to provide you with offers, promotions, and information.

Information We Collect Through Automatic Data Collection Technology. As you navigate through our Website and landing pages, we may use automatic data collection technologies including Google Analytics to collect certain information about your equipment, browsing actions, and patterns. This will generally include information about your location, your traffic pattern through our website, and any communications between your computer and our Website.  Among other things, we will collect data about the type of computer you use, your Internet connection, your IP address, your operating system, and your browser type.

The information we collect automatically is used for statistical data and will not include personal information. We use this data to improve our Website and our service offerings. To the extent that you voluntarily provide personal information to us, our systems will associate the automatically collected information with your personal information.

Use of Cookies And Pixels

Similar to other commercial websites, our website utilizes a standard technology called “cookies” and server logs to collect information about how our site is used. Information gathered through cookies and server logs may include the date and time of visits, the pages viewed, time spent at our site, and the websites visited just before and just after our own, as well as your IP address.

A cookie is a very small text document, which often includes an anonymous unique identifier. When you visit a website, that site’s computer asks your computer for permission to store this file in a part of your hard drive specifically designated for cookies. Each website can send its own cookie to your browser if your browser’s preferences allow it, but (to protect your privacy) your browser only permits a website to access the cookies it has already sent to you, not the cookies sent to you by other sites.

The Company reserves the right to use technological equivalents of cookies, including social media pixels. These pixels allow social media sites to track visitors to outside websites so as to tailor advertising messages users see while visiting that social media website. The Company reserves the right to use these pixels in compliance with the policies of the various social media sites.

Third Party Use Of Cookies

Some content or applications, including advertisements, on the Website are served by third-parties, including advertisers, ad networks and servers, content providers, and application providers. These third parties may use cookies alone or in conjunction with web beacons or other tracking technologies to collect information about you when you use our website. The information they collect may be associated with your personal information or they may collect information, including personal information, about your online activities over time and across different websites and other online services. They may use this information to provide you with interest-based (behavioral) advertising or other targeted content.

We do not control these third parties' tracking technologies or how they may be used. If you have any questions about an advertisement or other targeted content, you should contact the responsible provider directly.

Email Information

If you choose to correspond with us through email, we may retain the content of your email messages together with your email address and our responses. We provide the same protections for these electronic communications that we employ in the maintenance of information received online, mail, and telephone. This also applies when you register for our website, sign up through any of our forms using your email address or make a purchase on this site. For further information see the email policies below.

Email Policies

We are committed to keeping your e-mail address confidential. We do not sell, rent, or lease our subscription lists to third parties, and will not disclose your email address to any third parties except as allowed in the section titled Disclosure of Your Information.

We will maintain the information you send via e-mail in accordance with applicable federal law.

In compliance with the CAN-SPAM Act, all e-mails sent from our organization will clearly state who the e-mail is from and provide clear information on how to contact the sender. In addition, all e-mail messages will also contain concise information on how to remove yourself from our mailing list so that you receive no further e-mail communication from us.

Our emails provide users the opportunity to opt-out of receiving communications from us and our partners by reading the unsubscribe instructions located at the bottom of any e-mail they receive from us at anytime.

Users who no longer wish to receive our newsletter or promotional materials may opt-out of receiving these communications by clicking on the unsubscribe link in the e-mail.

How And Why We Collect Information

The Company collects your information in order to record and support your participation in the activities you select. If you register to download a book or resources, sign up for our newsletter, and/or purchase a product from us, we collect your information. We use this information to track your preferences and to keep you informed about the products and services you have selected to receive and any related products and/or services. As a visitor to this Website, you can engage in most activities without providing any personal information. It is only when you seek to download resources and/or register for services that you are required to provide information.

If you are outside the European Union and opt to receive any free resources, participate in any free training programs, register for a webinar, register for a live event, register for a seminar, or purchase any products sold by the Company on this Website, we will automatically enroll you to receive our free email newsletter. If you do not wish to receive this newsletter, you can unsubscribe anytime. We include an “unsubscribe” link at the bottom of every email we send. If you ever have trouble unsubscribing, you can send an email to teresa@teresalodato.com requesting to unsubscribe from future emails.

If you are in the European Union and opt to receive any free resources, participate in any free training programs, register for a webinar, register for a live event, register for a seminar, or purchase any products sold by the Company on this Website, we will only enroll you to receive our free email newsletter if you affirmatively consent to it. If you do not wish to receive this newsletter, you can unsubscribe anytime. We include an “unsubscribe” link at the bottom of every email we send. If you ever have trouble unsubscribing, you can send an email to teresa@teresalodato.com requesting to unsubscribe from future emails.

How Do We Use the Information That You Provide to Us?

We use personal information for purposes of presenting our Website and its contents to you, providing you with information, providing you with offers for products and services, providing you with information about your subscriptions and products, carrying out any contract between you and the Company, administering our business activities, providing customer service, and making available other items and services to our customers and prospective customers.

From time-to-time, we may use the information you provide to us to make you offers to purchase products and services provided by third parties in exchange for a commission to be paid to us by such third parties. Should you opt to take part in such promotions, the third parties will receive your information.

From time-to-time, we may use the information you provide to us to display advertisements to you that are tailored to your personal characteristics, interests, and activities.

Disclosure Of Your Information

As a general rule, we do not sell, rent, lease or otherwise transfer any information collected whether automatically or through your voluntary action.

We may disclose your personal information to our subsidiaries, affiliates, and service providers for the purpose of providing our services to you.

We may disclose your personal information to a third party, including a lawyer or collection agency, when necessary to enforce our terms of service or any other agreement between you and the Company.

We may provide your information to any successor in interest in the event of a merger, divestiture, restructuring, reorganization, dissolution, or other sale or transfer of some or all of the Company’s asserts and/or business.

We may disclose information when legally compelled to do so, in other words, when we, in good faith, believe that the law requires it or for the protection of our legal rights or when compelled by a court or other governmental entity to do so.

How Do We Protect Your Information and Secure Information Transmissions?

We employ commercially reasonable methods to ensure the security of the information you provide to us and the information we collect automatically. This includes using standard security protocols and working only with reputable third-party vendors.

Email is not recognized as a secure medium of communication. For this reason, we request that you do not send private information to us by email. However, doing so is allowed, but at your own risk. Some of the information you may enter on our website may be transmitted securely via a secure medium known as Secure Sockets Layer, or SSL. Credit Card information and other sensitive information is never transmitted via email.

The Company may use software programs to create summary statistics, which are used for such purposes as assessing the number of visitors to the different sections of our site, what information is of most and least interest, determining technical design specifications, and identifying system performance or problem areas.

For site security purposes and to ensure that this service remains available to all users, the Company uses software programs to monitor network traffic to identify unauthorized attempts to upload or change information, or otherwise cause damage.

Policy Changes

It is our policy to post any changes we make to our privacy policy on this page. If we make material changes to how we treat our users' personal information, we will notify you by email to the email address specified in your account and/or through a notice on the Website home page. The date the privacy policy was last revised is identified at the bottom of the page. You are responsible for ensuring we have an up-to-date active and deliverable email address for you, and for periodically visiting our Website and this privacy policy to check for any changes.

Visitors’ GDPR Rights

If you are within the European Union, you are entitled to certain information and have certain rights under the General Data Protection Regulation. Those rights include:

We will retain the any information you choose to provide to us until the earlier of: (a) you asking us to delete the information, (b) our decision to cease using our existing data providers, or (c) the Company decides that the value in retaining the data is outweighed by the costs of retaining it.

You have the right to request access to your data that the Company stores and the rights to either rectify or erase your personal data.

You have the right to seek restrictions on the processing of your data.

You have the right to object to the processing of your data and the right to the portability of your data.

To the extent that you provided consent to the Company’s processing of your personal data, you have the right to withdraw that consent at any time, without affecting the lawfulness of processing based upon consent that occurred prior to your withdrawal of consent.

You have the right to lodge a complaint with a supervisory authority that has jurisdiction over issues related to the General Data Protection Regulation.

We require only the information that is reasonably required to enter into a contract with you. We will not require you to provide consent for any unnecessary processing as a condition of entering into a contract with us.


Contact Us

The Company welcomes your questions or comments regarding the Privacy Policy:

Teresa Lodato, CPCC
160 Alamo Plz, Ste. 1294
Alamo, California 94507

Email Address: teresa@teresalodato.com



Effective as of July 1st, 2020

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